Arrowe Park Hospital
Requires improvement

Reports

Inspection carried out on 15 – 18 and 24 September 2015

During a routine inspection

Arrowe Park Hospital is one of two hospital sites managed by Wirral University Teaching Hospitals NHS Foundation Trust. The hospital is the main site and provides a full range of hospital services including emergency care, critical care, a comprehensive range of elective and non-elective general medicine (including elderly care) and surgery, a neonatal unit, children and young people’s services, maternity and gynaecology services and a range of outpatient and diagnostic imaging services.

The hospital is located on the Wirral peninsula in the North West of England and serves the people of Wirral and neighbouring areas.

Wirral University Teaching Hospitals NHS Foundation Trust became a Foundation Trust on 1 July 2007. The trust provides services for around 400,000 people across Wirral, Ellesmere Port, Neston, North Wales and the wider North West footprint with 855 beds trust-wide, including 749 at Arrowe Park Hospital.

We previously inspected this hospital in May 2015 as part of a responsive unannounced inspection and found that there were shortages of nursing staff on some medical wards which we told the trust to address.

We carried out an announced inspection of Arrowe Park Hospital on 16 – 18 September 2015 as part of our comprehensive inspection of Wirral University Teaching Hospitals NHS Foundation Trust and we checked to make sure staffing levels had improved.

Overall, we rated Arrowe Park Hospital as ‘Requires Improvement’. We have judged the hospital as ‘good’ for caring. We found that services were provided by dedicated, caring staff and patients were treated with dignity and respect. However, improvements were needed to ensure that services were safe, effective, well led and responsive to people’s needs.

Our key findings were as follows:

Cleanliness and infection control

The trust had infection prevention and control policies in place which were accessible to staff.

Staff generally followed good practice guidance in relation to the control and prevention of infection in line with trust policies and procedures. However, in the critical care unit not all staff followed ‘bare below the elbows’ guidance and there was mixed levels of compliance with hand hygiene protocols.

‘I am clean’ stickers were used to inform staff at a glance that equipment or furniture had been cleaned and was ready for use.

There had been no cases of methicillin resistant staphylococcus aureus (MRSA) bacteraemia infections or clostridium difficile infections identified in surgical services across the trust between March 2015 and August 2015. However, across the same period, medical care services reported 21 cases of clostridium difficile infections, two cases of MRSA and six cases of MSSA. The data could not be split so as to separate cases that specifically occurred at Arrowe Park Hospital.

According to the submitted and verified intensive care national audit and research centre data (ICNARC), the critical care unit performed as well and sometimes better than similar units for unit acquired MRSA and clostridium difficile infection rates.

Side rooms were used where possible as isolation rooms for patients at increased risk of cross infection. There was clear signage outside the rooms so that staff were aware of the increased precautions they must take when entering and leaving the room.

We observed that the disposal of sharps, such as needle sticks followed good practice guidance. Sharps containers were dated and signed upon assembling them and the temporary closure was used when sharps containers were not in use.

Patient-led assessments of the care environment (PLACE) audits for 2013 and 2014 scored higher than the national average for cleanliness across the trust, specific data for Arrowe Park Hospital was not available.

Nurse staffing

We previously inspected this hospital in May 2015 as part of a responsive unannounced inspection and found that there were shortages of nursing staff on some medical wards which we told the trust to address.

The trust had responded positively to our last inspection and had actively recruited nursing staff in a variety of ways to improve staffing levels. However, there were still staffing shortfalls across the hospital.

To attempt to address shortfalls in staffing, matrons met each day to discuss nurse staffing levels across the divisions to ensure that there was good allocation of staff and skills were appropriately deployed and shared across all wards. In July 2015 there were still 70 nursing vacancies in medical and acute services across the trust.

The trust had a high vacancy rate for nursing staff in medical services trust wide, which was 13% at the time of the inspection. The turnover of nursing staff was 9.7%.

The vacancy rate for nurses in surgical services was below 3% for the five month period prior to the inspection. At the time of the inspection the vacancy rate for nurses across surgical services trust-wide was 2.4%.

There was no recognised acuity tool in use to determine staffing numbers on paediatric wards. A band 6 nurse devised the staff rota and the skill mix of each shift was based on their knowledge of individual staff competencies.

The staffing and skill mix on surgical ward areas and in theatre areas was sufficient, with some periods of reduced staffing in areas because of last minute sickness and unexpected events. However, there was a lack of surgical staff trained in paediatric life support. This training was not mandatory for staff, despite them regularly working with children.

Medical staffing

Medical treatment was delivered by skilled and committed medical staff.

The information we reviewed showed that medical staffing was generally sufficient at the time of the inspection.

The trust had identified areas, such as the emergency department and medical specialties, where medical staff shortages presented a risk to patient care and treatment and were working hard to recruit and retain consultants.

The vacancy rate for medical staff was 12.4% and the turnover of medical staff in medical services trust wide was 18% at the time of the inspection.

The total number of shifts covered by locum medical staff in medical services trust wide, between April 2015 and September 2015, was 1,428. This was for a number of reasons including vacancies, extra staffing over and above the normal levels and extra ward rounds. Locums were either trust staff working extra shifts or from an agency.

The number of palliative care consultants was below the Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care guidance.

There were 57.4 whole time equivalent (WTE) vacancies across all staffing in the diagnostics and imaging services as of August 2015.

Mortality rates

Monthly governance meetings were in place where mortality, incidents and actions were discussed. Information was then cascaded to senior staff via email to enable sharing with other staff. However, in medical services it was unclear if any actions for improvement were agreed at the meeting.

The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators which is used to measure mortality outcomes at trust level across the NHS in England using a standard and transparent methodology. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated at the hospital. The risk score is the ratio between the actual and expected number of adverse outcomes. A score of 100 would mean that the number of adverse outcomes is as expected compared to England. A score of over 100 means more adverse (worse) outcomes than expected and a score of less than 100 means less adverse (better) outcomes than expected. Between October 2013 and September 2014 the trust score was 97.

Nutrition and hydration

The majority of patients we spoke with said they were happy with the standard and choice of food available.

In the CQC accident and emergency patient survey 2014, patients gave the emergency department a score of seven out of ten for being able to access suitable food or drink whilst in the department.

Staff in surgical services managed the nutrition and hydration needs of patient’s well, both pre and post operatively. Patients were given information in the form of leaflets about their surgery and told how long they would need to fast pre-operatively.

In all the records we reviewed, a nutritional risk assessment had been completed and updated regularly. This helped identify patients at risk of malnutrition and adapt to any ongoing nutritional or hydration needs.

A coloured tray system was in place to highlight which patients needed assistance with eating and drinking. The trust had an internal target to ensure that 75% of patients got assistance with eating when they required it. Information provided by the trust showed that they were not meeting this target in medical specialties.

Staff consistently completed charts used to record patients’ fluid input and output and where appropriate staff escalated any concerns.

The trust was awarded UNICEF baby friendly accreditation in July 2014 for work related to supporting breastfeeding and parent infant relationships.

We saw areas of outstanding practice including:

Senior clinicians on the emergency surgical assessment unit had recognised that fluid balance monitoring could be improved and introduced a training programme for health care support workers to achieve this aim. Health care support workers told us they felt empowered by the training and saw fluid balance monitoring as an integral part of their role after it. Audits showed that the completion of fluid balance charts had improved since the training and senior clinicians reported that there had been a significant reduction in the number of patients developing acute kidney injuries (a condition associated with dehydration).

The sentinel stroke national audit programme (SSNAP) latest audit results rated the trust overall as a grade ‘A’ which was an improvement from the previous audit results when the trust was rated as a grade ‘B’. Since October 2014 the trust had either been ranked first or second regionally in the SSNAP audit.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the hospital must:

Urgent and emergency care

Ensure call bells are available in every bay and placed with patients.

Staffing continues to remain a focus and that shifts are adequately staffed to meet the needs of patients.

Ensure that risks are always managed and mitigated in a timely way.

Medical care (including older people’s care)

The trust must ensure that robust information is collected and analysed to support improvements in clinical and operational practice.

The trust must ensure that care and treatment is only provided with the consent of the relevant person and if a patient lacks capacity to consent, the Mental Capacity Act (2005) principles are adhered to. This must be supported by staff receiving training in consent and the principles of the 2005 act.

The trust must deploy sufficient staff with the appropriate skills on wards, especially on the medical short stay ward and on ward 16 at night.

The trust must ensure that learning is shared across all service areas and the reasons for any changes made clear to all staff.

The trust must ensure that records are kept secure at all times so that they are only accessed and amended by authorised people.

Surgery

The trust must ensure that there are adequate numbers of suitably qualified staff in theatre recovery areas to ensure safe patient care.

The trust must ensure that all staff involved with the care and treatment of children receive adequate life support training.

The trust must ensure that all staff receive are appropriately trained and able to use the incident reporting system.

Critical care

The trust must address the governance shortfalls in critical care and make sure that the systems and processes in place for assessing, monitoring and mitigating local risk are managed effectively.

The trust must ensure that all staff understand the thresholds for reporting incidents and are encouraged to use the electronic reporting system.

The trust must make sure that all staff understand and comply with the best practice in infection prevention and control. This includes appropriate use of handwashing and the use of antiseptic hand gels.

Maternity and gynaecology

Review the management of the electronic rostering system to ensure it does not allow staff to be rostered on different wards at the same time.

The provider must deploy sufficient clinical and midwifery staff with the appropriate skills at all times of the day and night to meet the needs of women following the trust risk assessment and escalation procedures.

The provider must ensure that there is a detailed overview of the types and seriousness of incidents and learning is shared across all service areas and the reasons for any changes made clear to all staff.

The provider must make sure individual care records are always accurate and completed contemporaneously.

The provider must make sure community midwives have easy access to the emergency medication and equipment detailed in best practice guidance. The equipment must be checked and items provided within the use by date.

Children and young people’s services

Resuscitation trolleys must be appropriately checked and the log book must be signed to confirm all items are in working order. The trolley must include a defibrillator at all times.

Must ensure that there is a robust system to determine staffing numbers which takes into account the acuity of patients and skill mix of staff.

Information must be collected and analysed to support developments in clinical and operational practice.

Must review the children’s safeguarding training to ensure it meets Royal College of Paediatrics and Child Health (RCPCH) guidelines 2014.

End of life

Ensure that any complaint received is investigated and necessary and proportionate action is taken in response to any failures identified by the complaint or investigation.

Seek and act on feedback from relevant persons and staff teams, for the purpose of continually evaluating and improving services.

Evaluate and improve their practice in respect of the processing of information relating to the quality of people’s experience.

Ensure there is a robust vision and strategy for end of life services and all staff are aware of them.

Ensure that there is an appropriate replacement care plan in place across the trust following the withdrawal of the Liverpool Care Pathway.

Ensure that all risks associated with end of life services are recorded and monitored with appropriate actions taken to mitigate them.

Outpatients and diagnostics

The trust must take action to reduce the delay in referral to reporting times of urgent diagnostic investigations.

The trust must resume radiation safety committee meetings and hold them at least annually.

The trust must take steps to fill vacancies to ensure compliance against their current staffing establishment.

In addition the trust should:

Urgent and emergency care

Review and introduce regular audits of patient records to ensure all relevant details are correctly sourced and recorded.

Review and evaluate the outcomes from use of the potential sepsis warning tool.

Take action to address waiting times and the access and flow through the hospital.

Medical care (including older people’s care)

The trust should ensure that hazardous chemicals are stored appropriately in a locked cupboard when not in use.

The trust should ensure that the acuity of patients on the coronary care unit is regularly assessed to ensure there is an appropriate skill mix of staff.

The trust should ensure that trolleys used to store records and sharp instruments are kept secure when not being used.

The trust should ensure those patients are discharged as soon as they are fit to do so.

The trust should ensure that patients are not moved ward more than is necessary during their admission and are cared for on a ward suited to meet their needs.

The trust should ensure that patients’ views are sought to help inform changes to services provided.

The trust should ensure that actions to improve standards of medicines management are identified in a timely way.

The trust must consider implementing formal procedures for the supervision of staff to enable them to carry out the duties they are employed to perform.

Surgery

The trust should ensure that the emergency surgical assessment unit is not used for medical outliers.

The trust should ensure that patients are not kept in theatre recovery areas for long periods of time or overnight.

Critical care

The trust should ensure that all equipment is regularly serviced, maintained and remains fit for purpose.

The trust should ensure that all patient records are accurate and fit for purpose.

The trust should ensure that any delayed discharges from critical care do not result in a breach of the government’s single sex standard.

The trust should consider developing to plans to indicate when facilities will be upgraded to comply with the current HBN 04-02. It is imperative that critical care is delivered in facilities designed for that purpose.

The trust should consider how it is going to improve performance in reducing the number of delayed and out of hours discharges of patients from critical care.

The trust should consider articulating a vision and strategy for the critical care service and communicating this to its staff.

Maternity and gynaecology

The provider should ensure women and babies who are subject to safeguarding or child protection concerns have their needs reviewed before they are discharged from the maternity service.

The provider should consider making it possible for all staff to be able to complete incidents directly onto the system

The provider should make sure the arrangements for managing medicines and medical gases keep people safe and meet the relevant best practice guidance.

The provider should ensure the general public are given opportunities to comment on their strategic plans.

The provider should consider providing written information in different languages.

The provider should consider maternity and gynaecology working more closely together so that effective systems can be shared.

The provider should consider ways of improving staff satisfaction with working for maternity services at Arrowe Park Hospital.

Children and young people’s services

The patient electronic system in the emergency department should include a safeguarding identifier to inform staff of known safeguarding concerns.

The trust should consider adding a paediatric nurse to the trust wide safeguarding team.

A robust development plan should be in place to improve staff skills.

The cot space on the neonatal ward should meet British Association of Perinatal Medicine (BAPM) standards.

There should be more integrated working between the wards and the children’s assessment unit.

All equipment in all areas of the children ward, neonatal unit and the children’s assessment unit should be tested for electrical safety and all plug sockets should have safety plugs.

There should be an active board level representative for children and young people’s services.

End of life

Ensure policies and protocols are reviewed and monitored regularly to ensure their effectiveness and implementation is consistent across the trust.

Outpatients and diagnostics

The trust should take steps to ensure that equipment is available and fit for use with minimal disruption to the service.

The trust should ensure that medication is not left unattended when not in use.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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During an inspection to make sure that the improvements required had been made

Arrowe Park Hospital is part of Wirral University Teaching Hospital NHS Foundation Trust. This is one of the biggest and acute trusts in the North West. Arrowe Park Hospital delivers emergency and acute services for children and adults.

The Care Quality Commission (CQC) conducted this focussed inspection in response to a number of concerns that were reported to us relating to the theatre recovery area being used as part of the trust escalation processes and procedures when they were short of inpatient beds. These concerns related to unsuitable facilities and inappropriate staffing and the medical wards 25 and 37 not having suitable staffing arrangements in place. Concerns had previously been raised that staffing numbers were not sufficient to meet people’s needs and a requirement to address this had been made at the last inspection in September 2014.

We inspected the hospital in the evening of 18 May 2015. We visited five ward areas, spoke to staff of different grades and reviewed the care record of one patient.

We visited the following wards:

Theatre recovery

Medical assessment unit

Surgical assessment unit

Ward 25 – escalation ward

Ward 37 – respiratory ward

Ward 38 – respiratory ward

We found the hospital to require improvement. This was because we found limited assurance about safety and that systems and processes for escalation, were not always appropriate to keep people safe. Escalation processes was how the Trust dealt with variation in demand and adjustments to bed capacity. Theatre Recovery used for escalation was not suitable for the purpose for which it was being used. There were periods of understaffing or inappropriate skills mix, which were not addressed quickly.

Our key findings were as follows:

There was general good practice with regard to infection control with documented action plans to address an outbreak of infection.

The care delivered was person centred and staff interacted well with patients in their care. Staff knew each one by their name.

The quality of service in the escalation areas of the trust requires improvement. There were appropriate processes and procedures for ensuring the safety of patients during periods of increased demand, however these were not always fully implemented and one area was being used that was not identified in the policy and were not suitable a suitable environment for the care and treatment of patients.

Nurse staffing levels and skills mix in some of the wards we visited were varied. There were occasions when the wards were not suitably staffed to meet the care needs of patients in a timely way. The trust was taking action to address the nurse vacancy rate, but it remained evident that the wards were not always appropriately staffed.

Staff were using a national Early Warning tool to help monitor deterioration in a patient's condition. However, these were not always completed appropriately.

There were clear processes to identify fundamental standards of care but these were not being used consistently.

Importantly, the trust must:

ensure sufficient numbers of suitably qualified and experienced staff in all areas to ensure patient needs are consistently met.

ensure that all procedures to identify safe care are completed consistently and learning identified.

In addition the trust should:

take action to ensure that areas used for escalation purposes are suitable for the service provided and that there are adequate support facilities and amenities.

ensure that recruitment processes identified are fully implemented

ensure that patient’s privacy and dignity is maintained at all times as part of the bed management procedures

Professor Sir Mike Richards

Chief Inspector of Hospitals

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During an inspection in response to concerns

We conducted this inspection in response to a number of concerns that were reported to us relating to poor patient care and unsafe discharges. Specific concerns were raised that Ward 1 (surgical day case unit) was being used for patients being transferred from Accident and Emergency (A&E) and related to unsuitable bathing facilities for a mixed sex unit. We raised these concerns with senior hospital management alongside concerns around shortfalls in nutritional action plans for patients and requested an investigation into the care of a patient as a result. We found the system in place for monitoring the care practices for patients was inadequate which puts patients at risk of not having their needs met.

We visited six wards and departments in the hospital, spoke to patients and staff of different grades and reviewed case notes. We observed inconsistencies in the care being delivered in each area we inspected. All the nurses and support workers we observed talked to patients in a kind and professional manner.

We visited the following wards:

Accident and emergency (A & E)

Wards 21 and 22– Care of the Elderly Wards

Ward 1 –Surgical Day Case Unit

Ward 20 – Urology Ward

Ward 33 – Heart Assessment Centre, Cardiology and Renal Ward

On the above wards and departments we spoke with care support workers, staff nurses, ward managers, the deputy associate director of nursing for medicine and the matrons for surgery. In addition we spoke with the director of nursing and midwifery, the associate director of operations for medicines and acute specialties, associate director of operations for surgery and the head of human resources.

We found that the trust needed to take more action to ensure the records made by staff were accurate and promoted the wellbeing and safety of patients because records were incomplete on the care of the elderly wards.

We found the trust had some established quality governance systems in place from ward to board level. We did not have confidence that quality assurance and monitoring processes were sufficiently robust to effectively assess and monitor the quality of service that people received. Areas of ongoing work that required further improvement include the board assurance framework and the risk register.

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During a routine inspection

We spoke with patients, relatives and staff at this inspection. We visited three wards and the theatre department. Most of the patients and relatives spoke positively about their experience and care they received. They provided comments such as:

“I’m treated very well. Staff treat me with love and kindness. We’re on friendly names. There is a close bond between myself and staff. They give me a choice of meals. I’m always asked what I’d like to eat. They do ask me if I like the food”,

“I think she’s getting the care and support she needs here”.

We found that when patients were admitted their needs were assessed and a plan of care was put into place. We found that the care plans were standardised and sometimes inflexible to patients needs when variances were identified. We found that patients who had a diagnosis of dementia were supported and cared for with a comprehensive assessment and care plan that met their needs. We found that discharge planning was generally effective.

We looked at staffing levels and support for staff. We found that staff on one ward experienced stress due to staffing levels. We were satisfied measures had been implemented to ensure suitable staffing and support on this ward. We found elsewhere that generally staff were appraised, trained and supported to undertake their roles effectively.

The trust had a robust governance framework in place that included systems and processes in place for monitoring the quality of services and risk management.

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During a check to make sure that the improvements required had been made

We followed up the area of non compliance identified in a previous inspection. We reviewed evidence that demonstrated the provider’s compliance in this area. Audit information demonstrated improvements in compliance against record keeping standards. Initiatives had been implemented to raise awareness of good record keeping and adherence to the record keeping standards.

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During a routine inspection

This was a scheduled inspection of Arrowe Park Hospital location. We focussed the visit on two areas of the hospital where concerns had been raised. We visited the Women’s and Children’s unit and medical unit. People we spoke with were mainly very positive about their experience at Arrowe Park Hospital. Patients and relatives told us:

“We are really well looked after, they are excellent with my baby as well as looking after me”,

“They can’t do enough for you, the care is excellent”,

“It’s been absolutely excellent – the whole journey”.

Patients and relatives told us they were treated well and with dignity and respect. They told us they received plenty of information regarding their care and treatment; however some patients on the maternity unit told us they would have liked more information and support with feeding their baby.

We found in the areas we visited there were suitable levels of qualified, knowledgeable and experienced staff.

Patients on the maternity unit told us their pain was managed well and that staff always checked with them on a regular basis how comfortable they were or if they were experiencing pain.

We found that the trust had suitable systems in place for monitoring the quality of services and learning and improving from audits, accidents, incidents, feedback and complaints.

We found improvements were needed in relation to accuracy of records and record keeping on the maternity unit.

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During an inspection to make sure that the improvements required had been made

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that improvements had been made and no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

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During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

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During an inspection to make sure that the improvements required had been made

We visited Arrowe Park Hospital and spoke to patients and relatives. Patients told us they felt they were well cared for and were well looked after. Comments made included:

“Everything is great, I have no complaints”, “I am very well cared for”, “They are very good and the staff are very nice”, “The care is good and so is the food”.

Patients told us the staff treated them with dignity and respect and the food was very nice with good choices. We were told they usually answered the call bell in a timely manner, however on occasions they had to wait as staff were busy with other patients.

Relatives of patients told us they were pleased with the care as their relatives had told them they were well looked after. Two of the relatives we spoke with felt communication between the ward staff and they should have been better. They said they were disappointed in having to ask for information regarding their relatives on a number of occasions before the information was forthcoming. Other family members felt they were kept informed as their relative had told them what was happening and gave them the information they needed.

We spoke with five patients about their medicines. None of them raised any direct concerns about the way their medicines were handled. One patient said they were looking after their own medicines and they were ‘’pleased’’ that they could do this as it helped them retain some of their independence. They also said this meant they could take them when they wanted to and so they didn’t have to wait for nursing staff to give them.

Other patients said that they had been given information regarding their new medicines and said they had been well looked after and the new medicines had helped.

Inspection ratings

We rate most services according to how safe, effective, caring, responsive and well-led they are, using four levels:

Outstanding – the service is performing exceptionally well.

Good – the service is performing well and meeting our expectations.

Requires improvement – the service isn't performing as well as it should and we have told the service how it must improve.

Inadequate – the service is performing badly and we've taken enforcement action against the provider of the service.

No rating/under appeal/rating suspended – there are some services which we can’t rate, while some might be under appeal from the provider. Suspended ratings are being reviewed by us and will be published soon.

Ticks and crosses

We don't rate every type of service. For services we haven't rated we use ticks and crosses to show whether we've asked them to take further action or taken enforcement action against them.

There's no need for the service to take further action. If this service has not had a CQC inspection since it registered with us, our judgement may be based on our assessment of declarations and evidence supplied by the service.

The service must make improvements.

At least one standard in this area was not being met when we inspected the service and we have taken enforcement action.